Cardiologie clinique et expérimentale
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Delayed Sternal Closure in Cardiac Surgery

Siavash Saadat, Molly Schultheis, Joseph Romero, Anthony Azzolini, Karen Odroniec, Viktor Dombrovskiy, Peter Scholz, Aziz Ghaly, Anthony Lemaire, George Batsides and Leonard Lee

Background: Delayed sternal closure (DSC) has a reported incidence of 1.2%-4.2% in the adult cardiac surgical literature for indications including hemodynamic instability, marked myocardial edema, respiratory compromise, intractable bleeding, placement of assist devices, and persistent arrhythmias. The purpose of this study was to evaluate the incidence, survival, and morbidity of open chest management (OCM) patients who subsequently required DSC.

Methods: All data were collected from the Robert Wood Johnson University Hospital Cardiac Surgery Database. A total of 1261 patients who underwent cardiac surgery from January 2012 through June 2013 were analysed, evaluating postoperative morbidity and mortality, along with inciting conditions for the utilization of DSC. Chi-square and frequency analysis were performed using SAS 9.3 software (SAS Institute, NC).

Results: A total of 41/1261 (3.25%) cases resulted in DSC. Of the cases requiring DSC, 33/41 (80.5%) were men and 8/41 (19.5%) were women. Analysis revealed 11/41 (26.8%) of cases requiring delayed sternal closure were orthotopic heart transplants, 9/41(21.9%) insertion of ventricular (uni- or bi-ventricular) assist devices (VAD), 8/41 (19.5%) operations were coronary artery bypass graft (CABG), 4/41 (9.76%) were type A aortic dissection graft repairs, 2/41 (4.88%) were mitral valve repairs (MVR), 2/41 (4.88%) were aortic valve repair (AVR) combined with CABG, 2/41 (4.88%) were MVR with CABG, and 3/41 (7.32%) were other cardiac procedures. There were no incidences of superficial sternal infection or mediastinitis in the DSC cohort, while infection occurred in 3/1220 (0.25%) patients after conventional closure. Analysis of postoperative comorbidities revealed acceptable rates of postoperative stroke [2/41 (4.88%)], atrial fibrillation [6/41 (14.6%)], and renal failure [16/41 (39.0%)]. Overall mortality was 14/41 (34.2%). Reasons for planned DSC included bleeding 7/41 (17.1%), hemodynamic instability 11/41 (26.8%), elevated pulmonary artery (PA) pressures in 4/41 (9.76%), and coagulopathy in 19/41 (46.3%), while graft occlusion and valve dysfunction were not factors leading to the implementation of DSC.

Conclusion: DSC is a technique that can be readily used in patients who require OCM for various reasons following cardiac surgery. DSC does not appear to increase the risk of infectious complications. Although postoperative complications such as stroke, atrial fibrillation, and renal failure, along with an acceptable mortality rate, is reflective of the patients' morbid condition requiring OCM, DSC can be carried out with a relatively low incidence of sternal complications after cardiac surgery.